IN THE DISTRICT COURT OF JUDICIAL DISTRICT COUNTY, KANSAS THE STATE OF KANSAS vs. Case No. [Name] Defendant ORDER FOR EXPUNGEMENT Pursuant to K.S.A. 21-6614. On this day of 20, the Court considers the Petition for Expungement filed herein. The State appears by, assistant county/district attorney or designee. The petitioner appears pro se in person with [Attorney s name, if any]. Others appearing, if any, are:. The Court finds jurisdiction and venue are proper. Notice to parties and those required to receive notice has been given as required by law. The Court, upon agreement of the parties, having reviewed the file, having received the evidence, and/or having heard statements of counsel, finds as follows: 1. The full name of the petitioner is ; 2. The full name of the petitioner at the time of his/her arrest or conviction, if different than #1, was ; 3. The petitioner is a [Race] [Sex] born in [Year of Birth]; 4. The petitioner was arrested in County, Kansas on [Date] by [Law Enforcement Agency] and charged with the crime of ; Rev. KSJC 12/2017 Page 1 of 5
5. The petitioner was convicted of on [Date]; OR The petitioner was granted a diversion for the crime of on [Date]; 6. The convicting court or diverting authority was ; 7. The date of final discharge was ; 8. More than one three five seven ten years have elapsed since petitioner fulfilled the terms of a diversion agreement, satisfied the sentence imposed, or was discharged from probation, a community services program, parole, post-release supervision, conditional release or a suspended sentence; 9. The petitioner has not been convicted of a felony in the past two years and no proceeding involving any such crime is presently pending or being instituted against the petitioner; 10. The conviction for which expungement is sought is not one of the offenses set out in K.S.A. 21-6614(e), for which no expungement is permitted; 11. The petitioner s current circumstances and behavior warrant this expungement and this expungement is consistent with public welfare. 12. The petitioner shall disclose that the arrest, conviction or diversion occurred if asked about previous arrests, convictions or diversions: A. in any application for licensure as a private detective, private detective agency, certification as a firearms trainer pursuant to K.S.A. 75-7b21, and amendments thereto, or employment as a detective with a private detective agency, as defined by K.S.A. 75-7b01, and amendments thereto; as security personnel with a private patrol operator, as defined by K.S.A. 75-7b01, and amendments thereto; or with an institution as defined in K.S.A. 76-12a01, and amendments thereto, of the department for aging and disability services; Rev. KSJC 12/2017 Page 2 of 5
B. in any application for admission, or for an order of reinstatement, to the practice of law in this state; C. to aid in determining the petitioner's qualifications for employment with the Kansas lottery or for work in sensitive areas within the Kansas lottery as deemed appropriate by the executive director of the Kansas lottery; D. to aid in determining the petitioner's qualifications for executive director of the Kansas racing and gaming commission, for employment with the commission or for work in sensitive areas in parimutuel racing as deemed appropriate by the executive director of the commission, or to aid in determining qualifications for licensure or renewal of licensure by the commission; E. to aid in determining the petitioner's qualifications for the following under the Kansas expanded lottery act: (i) Lottery gaming facility manager or prospective manager, racetrack gaming facility manager or prospective manager, licensee or certificate holder; or (ii) an officer, director, employee, owner, agent or contractor thereof; F. upon application for a commercial driver's license under K.S.A. 8-2,125 through 8-2,142, and amendments thereto; G. to aid in determining the petitioner's qualifications to be an employee of the state gaming agency; H. to aid in determining the petitioner's qualifications to be an employee of a tribal gaming commission or to hold a license issued pursuant to a tribal-state gaming compact; I. in any application for registration as a broker-dealer, agent, investment adviser or investment adviser representative all as defined in K.S.A. 17-12a102, and amendments thereto; Rev. KSJC 12/2017 Page 3 of 5
J. in any application for employment as a law enforcement officer as defined in K.S.A. 22-2202 or K.S.A. 74-5602, and amendments thereto; K. for applications received on and after July 1, 2006, to aid in determining the petitioner's qualifications for a license to carry a concealed weapon pursuant to the personal and family protection act, K.S.A. 75-7c01 et seq., and amendments thereto; or L. for applications received on and after July 1, 2016, to aid in determining the petitioner's qualifications for a license to act as a bail enforcement agent pursuant to K.S.A. 75-7e01 through 75-7e09, and amendments thereto, and K.S.A. 50-6,141, and amendments thereto. 13. The petitioner shall also disclose that the arrest, conviction or diversion occurred in the following circumstances as deemed appropriate by the Court:. IT IS THEREFORE ORDERED that the petitioner s arrest record, conviction or diversion record herein, named above, shall be expunged. The Clerk of the District Court, upon receipt and filing herein, shall send a certified copy of the Order of Expungement to the Kansas Bureau of Investigation which shall notify the Federal Bureau of Investigation, the Secretary of Corrections, and any other criminal justice agency which may have a record of the arrest, conviction or diversion described herein. IT IS SO ORDERED this day of, 20. Judge of the District Court Rev. KSJC 12/2017 Page 4 of 5
Submitted by: Signature of Defendant/Defendant s Attorney Name(Print): [Supreme Court Number]: Address 1: Address 2: City, State, Zip: Telephone: [Fax Number]: [E-mail Address]: Approved by: Assistant County/District Attorney Name(Print): [Supreme Court Number]: Address 1: Address 2: City, State, Zip: Telephone: [Fax Number]: [E-mail Address]: Rev. KSJC 12/2017 Page 5 of 5